Pins and needles
Acupuncture as a therapy is practised worldwide, but has strong cultural ties with China and the Far East. It was first formalised by the Yellow Emperor in China about 2,600BC – although the therapy was probably ancient even then.
Acupuncture relies upon the insertion of a solid needle through the skin to stimulate the body and produce therapeutic effects. The present therapeutic systems of acupuncture are the results of centuries of observational medicine – reproducible effects identified by practitioners and used to provide a system of treatment for patients.
To many with a western medical or scientific education, the acupuncture system can seem bizarre and unbelievable. This is not helped by the use of names that appear to relate to structures but actually don’t (such as stomach meridian or gall bladder meridian), and concepts of the Yin and Yang, and the body’s life energy – the Chi.
Acupuncture has, however, enjoyed a renaissance over the past 30 or so years in the west, with a vast number of practitioners across the UK. Some have a traditional Chinese training, others a western training.
Some restrict their approach to specific systems – such as ear acupuncture, and some mix their practice with other therapies – traditional, or western such as physiotherapy.
Acupuncture as a therapy to use within dentistry has developed slowly – a few articles appeared in the 1980s and 1990s from practitioners who had integrated the technique into their practice, but a paper by Rosted reflected a growing interest in the possibility of the use of acupuncture by dentists.
This has since been followed by a number of further papers by the same and other authors looking at a range of applications for acupuncture to help dental patients. They now include: temporomandibular disorders (TMD), facial pain, chronic headache and migraine, neuralgias, post-operative pain, sinusitis and rhinitis, gagging and dental anxiety. Xerostomia can be helped in suitable patients by stimulating salivary activity – provided any active glandular tissue remains, and there are also suggestions that acupuncture may be helpful for oral dysaesthesias, and possibly apthous ulceration, although no evidence exists for this as yet.
Perhaps the most important and dramatic impact for dental treatment is the impact that acupuncture may have on controlling gagging.
Either of two main sites can dramatically reduce, and normally eliminate, gagging in most patients. As a consequence, the potentially traumatic treatment session can become routine. It is important to note that patients with gagging due to severe anxiety will not respond – and are best treated with Midazolam for anxiety control.
Needles are placed at specific sites – either on the chin, or above the tragus of the ear on both sides, or at all three sites. The effect is typically evident within 60 seconds, although may take a little longer in some cases, and has a reliability of around 80 per cent. The effect lasts while the needles are in place, and generally for a short time after – but normally does not give persistent changes in gagging sensitivity.
The technique is quick, cheap (needles are approximately 10p each), requires limited training, and has a very low risk of morbidity or complications. It also does not rely upon patient co-operation – unlike hypnosis, visualisation or distraction. Practitioners and patients alike are usually astounded at how effective the technique is.
A further adoption for the control of the gag reflex is following the fitting of new dentures. Some patients struggle to cope initially, and arm sites used for the control of nausea and vomiting may also be used to control of gagging – but require 20 minutes to take effect. Small indwelling needles can be placed on both arms and left in situ for several days while the patient adapts to the new denture, easing their transition. A combination of ear/chin points for the fitting of the denture followed by arm sites to follow on with is used.
Acupuncture may also be used to relax patients before or during their treatment. The approach relies upon the fact that acupuncture leads to a release of endorphins and serotonin within the central nervous system, and these produce both a relaxation of the patient and a change in mood – an effect that can last days for some patients.
A site in the midline, behind the vertex of the head, is used, sometimes with accessory supportive points, for this effect, although sedation as a side effect is seen with most acupuncture sites to a greater or lesser extent. When you have put half a dozen needles in the patient’s face and they go to sleep in the dental chair it reinforces the belief that acupuncture works!
Temporomandibular disorders are also well treated with acupuncture. Needling of the muscles of mastication can reduce pain, improve function, and reduce trismus. Clicking can also be improved or in some cases eliminated with needling – mainly to lateral pterygoid muscles. Typically masseter, anterior part of temporalis, and sometimes lateral pterygoids are needled, and responses can be dramatic – with reduction in symptoms obvious almost immediately in about 50 per cent of patients, some showing delayed improvement.
An average of four visits will normally significantly improve patients’ symptoms.
Effectively, acupuncture is part of a dynamic therapeutic approach to manage differing aspects of the patient’s symptoms. Headaches associated with TMD are also successfully treated with acupuncture. Recent Cochrane reviews indicate that acupuncture is as effective as conventional therapies for chronic headache and migraine prophylaxis, but with superior side effect profiles.
Outcomes with acupuncture are generally positive. Patient feedback is also usually positive, but occasionally responses can be delayed, taking two or three treatments to improve, and occasionally hyper-responders can feel unwell for several days following a treatment.
Some patients are unsuitable for acupuncture: atypical facial pain, and atypical odontalgia are poorly treated in most patients, and acupuncture will never replace local analgesia – although it may improve the effectiveness of analgesia.
Acupuncture should be used realistically – it will not cure caries, or an acute abscess – and dentists should remember they are dentists first!
About the author
Tom Thayer is chairman of the British Dental Acupuncture Society, consultant in oral surgery at Liverpool University Dental Hospital and Fellow of the Royal College of Physicians and Surgeons of Glasgow.